Original Article Mohammadi et al. 139
Non-surgical Management of Congenital Auricular Deformities Ali Akbar Mohammadi1*, Mohammad Taghi Imani1, Sina Kardeh1,2, Mehrab Mohammad Karami1, Masoomeh Kherad1 1.
2.
Shiraz Burn Research Center, Division of Plastic and Reconstructive Surgery, Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
*Corresponding Author: Ali Akbar Mohammadi, MD; Shiraz Burn Research Center, Division of Plastic and Reconstructive Surgery, Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran Tel: +98-711-8219640 Fax: +98-711-8217090 E-mail: [email protected] Received: November 8, 2015 Revised: February 7, 2016 Accepted: February 3, 2016
ABSTRACT BACKGROUND Unlike congenital auricular malformations which are identified by underdevelopment of dermal and cartilaginous tissues, deformed ears are less sever congenital anomalies characterized only by a misshaped pinna structure and can be improved with acceptable cosmetic results and minimal cost through ear molding if treated in early neonatal period. In this study, authors present the first report of using splinting techniques for treatment of deformational auricular anomalies in Iranian children. METHODS Our case load consisted of a series of 29 patients (Male=16, Female=13) who were referred to Plastic Surgery Unit of Shiraz University of Medical Sciences from September 2011 to December 2014. Children aged more than 6 moths were excluded. Twenty-nine children affected by various deformities including prominent ears (n=11), lop ears (n=8) and constricted ears (n=10) were treated by splintage as a nonsurgical technique. The mean time of treatment was 13.33±2 weeks. RESULTS Eight (27.6%) patients did not complete the treatment. Splinting resulted in excellent or satisfactory results in 12 (57.14%) of treated cases. No improvement was observed at the end of the molding treatment in 9 patients. No complication was observed during the treatment in any of the patients. CONCLUSION The nonsurgical molding can be used as an effective approach for achieving natural outcomes and correcting cosmetic abnormalities. Rate of satisfaction is dependent on type of deformity, the neonatal age in which treatment started and also parents’ adherence to treatment methods and principals. Concerning the low rate of complications and high satisfactory results the method can be used instead of surgery in appropriate cases. KEYWORDS Congenital auricular deformities; Non-surgical; Management Please cite this paper as: Mohammadi AA, Imani MT, Kardeh S, Karami MM, Kherad M. Nonsurgical Management of Congenital Auricular Deformities. World J Plast Surg 2016;5(2):139-147. www.wjps.ir /Vol.5/No.2/May 2016
140 Management of congenital auricular deformities INTRODUCTION Anomalies of the auricles can lead to substantial social and communicating difficulties in the growing children. Congenital ear anomalies are categorized into either malformations (microtia, cryptotia), which are mostly caused due to embryologic maldevelopment in fetal auricular cartilage framework between the fifth and the ninth gestational week, or deformations that only show an abnormal shape without any irregularities in chondro-cutaneous components. Partial absence of skin or cartilage in malformations results in a constricted or underdeveloped pinna requiring surgical intervention during childhood or adolescence for best treatment.1,2 On the other hand, deformities including lop, constricted and Stahl’s ear are less severe forms arising after the ninth week of gestation with a misshaped but fully developed pinna and structural cartilage. Although several distinct types exist, prominent or protruding ears are the most common variant.3 Lop ears are characterized by drooping upper pole, whereas Stahl’s ears have abnormal kinks of the helix combined with an anti-helical crus perpendicular to the helical rim.4 Congenital ear deformities are not usually caused by disturbance in the process of morphogenesis but rather result as a consequence of external positioning forces determined by the pressure or malinsertion of the seven intrinsic and four extrinsic muscles in the prenatal period.5 To improve the appearance of children with such deformities, otoplasty as a common cosmetic surgical procedure to the plastic surgeons, is usually performed under general anesthesia especially in younger children.6 However, despite the introduction of many different surgical techniques in the past decades for correction and rehabilitation of this irritating aesthetic handicap, considerable collateral complications and the uneventful course of postoperative care have caused great interest in avoiding surgery.7 Further, surgical correction of deformities is usually performed between 5 and 6 years of age when the auricle has reached about 90% of the adult size.8 The concept of applying mechanical forces by using mold casting to achieve a normal shape in congenital deformities has been previously established in treatment of hip dislocation and club foot. In the late 1980s, www.wjps.ir /Vol.5/No.2/May 2016
Japanese plastic surgeons published the first reports of non-surgical correction of congenital auricular deformities and demonstrated that permanent correction may occur by forcing and maintaining the ear into the proper position for several weeks.9-11 Currently, ear deformities are usually amenable to early ear splinting and can be appropriately manipulated to a normal shape in the neonatal period. As neonatal auricle is immediately soft and becomes harder in the first weeks after birth while loosing its innate elasticity, it is believed that the earlier the molding starts, better results are obtained.12 In this study, authors present the first experience of ear molding in a case load of 29 Iranian children with deformational auricular anomalies who were treated over a 4-year period. MATERIALS AND METHODS Prior to the conduction of study the ear molding as a possible technique that may be performed in early ages instead of otoplasty was described to the staff in different neonatal wards affiliated with Shiraz university of Medical sciences. Furthermore, to raise awareness of parents related posters were installed on community notification boards of hospitals in popular spots. From September 2011 to December 2014 twentynine patients suffering from various types of ear deformities, who were found to be suitable cases for ear molding, were referred to our plastic surgery ward by the neonatal staff. Children more than 6 months were also excluded. Prior to the start of treatment, patients were monitored for a 24 hours period to confirm that splinting was indicated and ears could not reform by spontaneous correction in a short or sudden course. Benefits of the proposed treatment in comparison to other alternatives and also the risks in achieving highly satisfactory results were thoroughly explained to the parents. Besides, an informed written consent was obtained from each participant’s parents in this study. The method we used was principally the same as the one described by Schonauer et al.13 Soft and flexible silicone with 4 mm diameter was used as the covering component of the splint whilst stainless steel wire was deployed within this segment (Figure 1a). Then, we curved the whole structure according to the desired shape and fixed it by
Mohammadi et al. 141
Fig. 1: Public poster for introducing non-surgical management of congenital auricular deformities.
surgical tapes on the anterolateral surface of the auricle in the groove between helix and antihelix as a supporting pillar. Surgical tapes could also help to position the auricle closer to the scalp (Figure 1b). Further, most patients wore elastic bonds as adjunct supporters to facilitate the process and keep the mold in place. Splinting was applied with no demand to any kinds of anesthetics. To prevent any complicated handling of the procedure by parents, we avoided using a second mold on the posteromedial aspect of the auricle as described in some previous studies. Clinical evaluations were made at follow up visits every 2 weeks after beginning of the treatment. In each session the splintage was removed, remodeled according to the achieved correction and then and reapplied with fresh steri strips. Photographs were taken at each visit. To stabilize the correct form of ear, molding was continued after achieving early satisfactory results for one more month and final inspection was performed at this point after completion of molding. The criteria for assessment of cosmetic results was categorized as excellent (>80% improvement), improved (50-80% improvement), or minimal to not improved (
Non-surgical Management of Congenital Auricular Deformities Ali Akbar Mohammadi1*, Mohammad Taghi Imani1, Sina Kardeh1,2, Mehrab Mohammad Karami1, Masoomeh Kherad1 1.
2.
Shiraz Burn Research Center, Division of Plastic and Reconstructive Surgery, Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
*Corresponding Author: Ali Akbar Mohammadi, MD; Shiraz Burn Research Center, Division of Plastic and Reconstructive Surgery, Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran Tel: +98-711-8219640 Fax: +98-711-8217090 E-mail: [email protected] Received: November 8, 2015 Revised: February 7, 2016 Accepted: February 3, 2016
ABSTRACT BACKGROUND Unlike congenital auricular malformations which are identified by underdevelopment of dermal and cartilaginous tissues, deformed ears are less sever congenital anomalies characterized only by a misshaped pinna structure and can be improved with acceptable cosmetic results and minimal cost through ear molding if treated in early neonatal period. In this study, authors present the first report of using splinting techniques for treatment of deformational auricular anomalies in Iranian children. METHODS Our case load consisted of a series of 29 patients (Male=16, Female=13) who were referred to Plastic Surgery Unit of Shiraz University of Medical Sciences from September 2011 to December 2014. Children aged more than 6 moths were excluded. Twenty-nine children affected by various deformities including prominent ears (n=11), lop ears (n=8) and constricted ears (n=10) were treated by splintage as a nonsurgical technique. The mean time of treatment was 13.33±2 weeks. RESULTS Eight (27.6%) patients did not complete the treatment. Splinting resulted in excellent or satisfactory results in 12 (57.14%) of treated cases. No improvement was observed at the end of the molding treatment in 9 patients. No complication was observed during the treatment in any of the patients. CONCLUSION The nonsurgical molding can be used as an effective approach for achieving natural outcomes and correcting cosmetic abnormalities. Rate of satisfaction is dependent on type of deformity, the neonatal age in which treatment started and also parents’ adherence to treatment methods and principals. Concerning the low rate of complications and high satisfactory results the method can be used instead of surgery in appropriate cases. KEYWORDS Congenital auricular deformities; Non-surgical; Management Please cite this paper as: Mohammadi AA, Imani MT, Kardeh S, Karami MM, Kherad M. Nonsurgical Management of Congenital Auricular Deformities. World J Plast Surg 2016;5(2):139-147. www.wjps.ir /Vol.5/No.2/May 2016
140 Management of congenital auricular deformities INTRODUCTION Anomalies of the auricles can lead to substantial social and communicating difficulties in the growing children. Congenital ear anomalies are categorized into either malformations (microtia, cryptotia), which are mostly caused due to embryologic maldevelopment in fetal auricular cartilage framework between the fifth and the ninth gestational week, or deformations that only show an abnormal shape without any irregularities in chondro-cutaneous components. Partial absence of skin or cartilage in malformations results in a constricted or underdeveloped pinna requiring surgical intervention during childhood or adolescence for best treatment.1,2 On the other hand, deformities including lop, constricted and Stahl’s ear are less severe forms arising after the ninth week of gestation with a misshaped but fully developed pinna and structural cartilage. Although several distinct types exist, prominent or protruding ears are the most common variant.3 Lop ears are characterized by drooping upper pole, whereas Stahl’s ears have abnormal kinks of the helix combined with an anti-helical crus perpendicular to the helical rim.4 Congenital ear deformities are not usually caused by disturbance in the process of morphogenesis but rather result as a consequence of external positioning forces determined by the pressure or malinsertion of the seven intrinsic and four extrinsic muscles in the prenatal period.5 To improve the appearance of children with such deformities, otoplasty as a common cosmetic surgical procedure to the plastic surgeons, is usually performed under general anesthesia especially in younger children.6 However, despite the introduction of many different surgical techniques in the past decades for correction and rehabilitation of this irritating aesthetic handicap, considerable collateral complications and the uneventful course of postoperative care have caused great interest in avoiding surgery.7 Further, surgical correction of deformities is usually performed between 5 and 6 years of age when the auricle has reached about 90% of the adult size.8 The concept of applying mechanical forces by using mold casting to achieve a normal shape in congenital deformities has been previously established in treatment of hip dislocation and club foot. In the late 1980s, www.wjps.ir /Vol.5/No.2/May 2016
Japanese plastic surgeons published the first reports of non-surgical correction of congenital auricular deformities and demonstrated that permanent correction may occur by forcing and maintaining the ear into the proper position for several weeks.9-11 Currently, ear deformities are usually amenable to early ear splinting and can be appropriately manipulated to a normal shape in the neonatal period. As neonatal auricle is immediately soft and becomes harder in the first weeks after birth while loosing its innate elasticity, it is believed that the earlier the molding starts, better results are obtained.12 In this study, authors present the first experience of ear molding in a case load of 29 Iranian children with deformational auricular anomalies who were treated over a 4-year period. MATERIALS AND METHODS Prior to the conduction of study the ear molding as a possible technique that may be performed in early ages instead of otoplasty was described to the staff in different neonatal wards affiliated with Shiraz university of Medical sciences. Furthermore, to raise awareness of parents related posters were installed on community notification boards of hospitals in popular spots. From September 2011 to December 2014 twentynine patients suffering from various types of ear deformities, who were found to be suitable cases for ear molding, were referred to our plastic surgery ward by the neonatal staff. Children more than 6 months were also excluded. Prior to the start of treatment, patients were monitored for a 24 hours period to confirm that splinting was indicated and ears could not reform by spontaneous correction in a short or sudden course. Benefits of the proposed treatment in comparison to other alternatives and also the risks in achieving highly satisfactory results were thoroughly explained to the parents. Besides, an informed written consent was obtained from each participant’s parents in this study. The method we used was principally the same as the one described by Schonauer et al.13 Soft and flexible silicone with 4 mm diameter was used as the covering component of the splint whilst stainless steel wire was deployed within this segment (Figure 1a). Then, we curved the whole structure according to the desired shape and fixed it by
Mohammadi et al. 141
Fig. 1: Public poster for introducing non-surgical management of congenital auricular deformities.
surgical tapes on the anterolateral surface of the auricle in the groove between helix and antihelix as a supporting pillar. Surgical tapes could also help to position the auricle closer to the scalp (Figure 1b). Further, most patients wore elastic bonds as adjunct supporters to facilitate the process and keep the mold in place. Splinting was applied with no demand to any kinds of anesthetics. To prevent any complicated handling of the procedure by parents, we avoided using a second mold on the posteromedial aspect of the auricle as described in some previous studies. Clinical evaluations were made at follow up visits every 2 weeks after beginning of the treatment. In each session the splintage was removed, remodeled according to the achieved correction and then and reapplied with fresh steri strips. Photographs were taken at each visit. To stabilize the correct form of ear, molding was continued after achieving early satisfactory results for one more month and final inspection was performed at this point after completion of molding. The criteria for assessment of cosmetic results was categorized as excellent (>80% improvement), improved (50-80% improvement), or minimal to not improved (
